A nurse is providing teaching to a client following surgery to repair a detached retina of the left eye. Which of the following instructions should the nurse include in the teaching?
Avoid reading for 3 months.
Pick up items by bending at the waist.
You can lift objects that weigh up to 50 pounds.
Take a stool softener daily.
The Correct Answer is D
Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Decreased BUN is not typical in preeclampsia, where renal impairment often elevates BUN due to reduced glomerular filtration. Normal or increased BUN is expected, so this finding does not align with preeclampsia’s pathophysiology, making it an incorrect expectation.
Choice B reason: Increased protein in urine (proteinuria) is a hallmark of preeclampsia, resulting from glomerular damage due to hypertension and endothelial dysfunction. This diagnostic criterion, often >300 mg/24 hours, is critical for identifying preeclampsia, making it the correct finding the nurse should expect.
Choice C reason: Increased platelet count is not associated with preeclampsia, which often causes thrombocytopenia due to endothelial activation and platelet consumption. A decreased count (<100,000/mm³) is more likely, making this finding incorrect for preeclampsia’s clinical presentation.
Choice D reason: Decreased serum uric acid is not expected in preeclampsia, where elevated uric acid occurs due to reduced renal clearance from glomerular dysfunction. Increased levels are a marker, so this finding is opposite to preeclampsia’s effects, making it incorrect.
Correct Answer is B
Explanation
Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.
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